Form NRC Form 5 NRC Form 5 Occupational Dose Record For A Monitoring Period

PAGE

NRC FORM 5

U.S. NUCLEAR REGULATORY COMMISSION

(9-2004)
10 CFR PART 20

EXPIRES: 09/30/2007

Estimated burden per response to comply with this mandatory collection request: 20 minutes. This information
is used to ensure that doses to individual do not exceed regulatory limits. This information is required to
record/annually report individual occupational exposure to radiation to ensure that the exposure does not
exceed regulatory limits. Send comments regarding burden estimate to the Records and FOIA/Privacy Services
Branch (T-5 F52), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to
[email protected], and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202,
(3150-0006), Office of Management and Budget, Washington, DC 20503. If a means used to impose an
information collection does not display a currently valid OMB control number, the NRC may not conduct or
sponsor, and a person is not required to respond to, the information collection.

OCCUPATIONAL DOSE RECORD
FOR A MONITORING PERIOD

1. NAME (LAST, FIRST, MIDDLE INITIAL)

APPROVED BY OMB NO.3150-0006

OF

2. IDENTIFICATION NUMBER

3. ID TYPE

4. SEX

5. DATE OF BIRTH
(MM/DD/YYYY)

MALE
FEMALE

6. MONITORING PERIOD (MM/DD/YYYY - MM/DD/YYYY) 7. LICENSEE NAME

8. LICENSE NUMBER(S)

9A.

9B.
RECORD

ROUTINE

ESTIMATE

PSE

INTAKES
10A. RADIONUCLIDE

10B. CLASS

10C. MODE

DOSES (in rem)

10D. INTAKE IN FCi
DEEP DOSE EQUIVALENT

(DDE) 11.

LENS (EYE) DOSE EQUIVALENT

(LDE) 12.

SHALLOW DOSE EQUIVALENT,
WHOLE BODY

(SDE,WB) 13.

SHALLOW DOSE EQUIVALENT,
MAX EXTREMITY

(SDE,ME) 14.

COMMITTED EFFECTIVE
DOSE EQUIVALENT

(CEDE) 15.

COMMITTED DOSE EQUIVALENT,
MAXIMALLY EXPOSED ORGAN

(CDE) 16.

TOTAL EFFECTIVE DOSE EQUIVALENT
(ADD BLOCKS 11 AND 15)

(TEDE)

TOTAL ORGAN DOSE EQUIVALENT
MAX ORGAN
(ADD BLOCKS 11 AND 16)

(TODE)

17.
18.

19. COMMENTS

20. SIGNATURE - LICENSEE

NRC FORM 5 (9-2004)

21. DATE PREPARED

PRINTED ON RECYCLED PAPER

INSTRUCTIONS AND ADDITIONAL INFORMATION PERTINENT TO THE
COMPLETION OF NRC FORM 5
(All doses should be stated in rems)
1.

Type or print the full name of the monitored
individual in the order of last name (include
"Jr," "Sr," "III," etc.), first name, middle initial (if
applicable).

2.

Enter the individual's identification number,
including punctuation. This number should be
the 9-digit social security number if at all
possible. If the individual has no social
security number, enter the number from
another official identification such as a
passport or work permit.

3.

Enter the code for the type of identification
used as shown below:
CODE ID TYPE
SSN U.S. Social Security Number
PPN Passport Number
CSI
Canadian Social Insurance Number
WPN Work Permit Number
PADS PADS Identification Number
OTH Other

4.

Check the box that denotes the sex of the
individual being monitored.

5.

Enter the date of birth of the individual being
monitored in the format MM/DD/YYYY.

6.

Enter the monitoring period for which this
report is filed. The format should be
MM/DD/YYYY - MM/DD/YYYY.

7.

Enter the name of the licensee.

8.

Enter the NRC license number or numbers.

9A. Place an "X" in Record, Estimate, or No
Record. Choose "Record" if the dose data
listed represent a final determination of the
dose received to the best of the licensee's
knowledge. Choose "Estimate" only if the
listed dose data are preliminary and will be
superseded by a final determination resulting
in a subsequent report. An example of such
an instance would be dose data based on
self-reading dosimeter results and the licensee
intends to assign the record dose on the basis
of TLD results that are not yet available.
9B. Place an "X" in either Routine or PSE.
Choose "Routine" if the data represent the
results of monitoring for routine exposures.
Choose "PSE" if the listed dose data
represents the results of monitoring of
planned special exposures received during the
monitoring period. If more than one PSE was
received in a single year, the licensee should
sum them and report the total of all PSEs.

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974
(Public Law 93-579), the following statement is furnished to individuals who supply
information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 5. This
information is maintained in a system of records designated as NRC-27 and described at 69
Federal Register 57601 (September 24, 2004), or the most recent Federal Register
10B. Enter the lung clearance class as listed in
Appendix B to 10 CFR Part 20.1001-2401 (D, publication of the NRC's "Republication of Systems of Records Notices" that is available at
the NRC Public Document Room, 11555 Rockville Pike, Rockville, Maryland or located in
W, Y, V, or O for other) for all intakes by
NRC's Agencywide Documents Access and Management System (ADAMS).
inhalation.
10A. Enter the symbol for each radionuclide that
resulted in an internal exposure recorded for
the individual, using the format "Xx-###x," for
instance, Cs-137 or Tc-99m.

10C. Enter the mode of intake. For inhalation,
enter "H." For absorption through the skin,
enter "B." For oral ingestion, enter "G." For
injection, enter "J."

1.

AUTHORITY: 5 U.S.C. 7902; 29 U.S.C. 668; 42 U.S.C. 2073, 2093, 2095, 2111,
2133, 2134, and 2201(o); 10 CFR 20.2106, 20.2201-20.2204, and 20.2206; Executive
Order 9397; Executive Order 12196.

2.

PRINCIPAL PURPOSE(S): The information is used by the NRC in its evaluation of
the risk of radiation exposure associated with the licensed activity and in exercising its
statutory responsibility to monitor and regulate the safety and health practices of its
licensees. The data permits a meaningful comparison of both current and long-term
exposure experience among types of licensees and among licensees within each type.
Data on your exposure to radiation is available to you upon your request.

3.

ROUTINE USE(S): The information may be used to provide data to other Federal and
State agencies involved in monitoring and/or evaluating radiation exposure received by
individuals monitored for radiation exposure while employed by or visiting or temporarily
assigned to certain NRC licensed facilities; to return data provided by licensee upon
request. The information may also be disclosed to an appropriate Federal, State, local
or Foreign agency in the event the information indicates a violation or potential violation
of law and in the course of an administrative or judicial proceeding. In addition, this
information may be transferred to an appropriate Federal, State, local and Foreign
agency to the extent relevant and necessary for an NRC decision about you or to the
extend relevant and necessary for that agency's decision about you. Information from
this form may also be disclosed, in the course of discovery and in presenting evidence,
to a Congressional office to respond to their inquiry made at your request, or to
NRC-paid experts, consultants, and others under contract with the NRC, on a
need-to-know basis.

10D. Enter the intake of each radionuclide in FCi.
11.

Enter the deep dose equivalent (DDE) to the
whole body.

12.

Enter the eye dose equivalent (LDE)
recorded for the lens of the eye.

13.

Enter the shallow dose equivalent recorded
for the skin of the whole body (SDE,WB).

14.

Enter the shallow dose equivalent recorded
for the skin of the extremity receiving the
maximum dose (SDE,ME).

15.

Enter the committed effective dose equivalent
(CEDE).

16.

Enter the committed dose equivalent (CDE)
recorded for the maximally exposed organ.

17.

Enter the total effective dose equivalent
(TEDE). The TEDE is the sum of items 11
and 15.

18.

Enter the total organ dose equivalent (TODE)
for the maximally exposed organ. The TODE
4.
is the sum of items 11 and 16.

19.

COMMENTS.
In the space provided, enter additional
information that might be needed to
determine compliance with limits. An
example might be to enter the note that the
SDE,ME was the result of exposure from a
discrete hot particle. Another possibility
would be to indicate that an overexposed
report has been sent to NRC in reference to
the exposure report.

20.

Signature of the person designated to
represent the licensee.

21.

Enter the date this form was prepared.

5.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON
INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the
requested information, including social security number (identification number);
however, the licensee must complete NRC Form 5 on each individual for whom
personnel monitoring is required under 10 CFR 20.2106. Failure to do so may subject
the licensee to enforcement action in accordance with 10 CFR 20.2401. The social
security number (identification number) is used to assure that NRC has an accurate
identifier not subject to the coincidence of similar names or birth dates among the large
number of persons on who data is maintained.
SYSTEM MANAGER(S) AND ADDRESS: REIRS Project Manager, Radiation
Protection, Environmental Risk, and Waste Management Branch, Division of Systems
Analysis and Regulatory Effectiveness, Office of Nuclear Regulatory Research, U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001.